Types of progress notes
There are six types of progress notes available on the platform.
Session Notes
Session notes are notes taken for the purpose of documenting or analyzing the content of a conversation during a therapy session.
When creating a session note, the following fields must be completed:
- Duration: Select from 15 minutes – 120 minutes.
- Method: Identify whether the session took place in person, by telephone, or video.
- Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.
- Visibility: Select who will be able to see the note:
- Clinic Only - Only admins will be able to see these notes.
- Therapists - Admins and any associated therapists will be able to see these notes.
- You can select Add Attachment to upload and store a file in connection with the session note.
Event Notes
You can create event notes to record brief observations to be overlayed onto the patient's results display. This feature might be used to note medication changes, significant life events or other relevant items to contextualize a patient’s results. Event notes are visible on the note summary page and overlayed on the progress graphs in a client's results display.
Note: Patients are able to view event notes.
Click here for more information about creating and viewing event notes.
Contact Notes
Therapists can use contact notes to reflect communication with their patients. Entries may include details on scheduling, follow-ups, and logistics. When creating a contact note, the following fields must be completed:
- Method: Identify whether the contact took place in person, by telephone, video, email, voicemail or fax.
- Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.
- Time: The current time is automatically selected, however you can adjust the time as necessary.
- Visibility: Select who will be able to see the note:
- Clinic Only - Only admins will be able to see these notes.
- Therapists - Admins and any associated therapists will be able to see these notes.
- Contact: You have the option of indicating who the contact was with in the Contact field.
- You can select Add Attachment to upload and store a file in connection with the contact note.
Supervision Notes
Supervision notes are notes used for the purpose of documenting a therapist's interaction with a supervisor or supervisee regarding a patient. When creating a supervision note, the following fields must be completed:
- Duration: Select from 15 minutes – 120 minutes.
- Method: Identify whether the session took place in person, by telephone, or video.
- Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.
- Visibility: Select who will be able to see the note:
- Clinic Only - Only admins will be able to see these notes.
- Therapists - Admins and any associated therapists will be able to see these notes.
- Contact: You have the option of indicating who the contact was with in the Contact field.
- You can select Add Attachment to upload and store a file in connection with the supervision note.
Documents
Therapists can use the document type to upload and store additional files such as administrative documents, patient assignments, medical records, and audio files. Multiple files can be uploaded within one document . When creating a document, the following fields must be completed:
- Title: Name your document.
- Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.
- Visibility: Select who will be able to see the note:
- Clinic Only - Only admins will be able to see these notes.
- Therapists - Admins and any associated therapists will be able to see these notes.
- Title: You have the option of indicating a title for the document.
- Description: Option to include a description of the document(s) in the text box below.
Treatment Summary
A Treatment Summary can be used for the purpose of summarizing a patient's treatment or planned treatment. This note is flexible and can be used before, during or after a patient's course of treatment.
When creating a treatment summary, the following fields must be completed:
- Duration: Select from 15 minutes – 120 minutes.
- Method: Identify whether the session took place in person, by telephone, or video.
- Date: Today's date is automatically selected, however you can select a different date by clicking on the calendar.
- Visibility: Select who will be able to see the note:
- Clinic Only - Only admins will be able to see these notes.
- Therapists - Admins and any associated therapists will be able to see these notes.
- Contact: You have the option of indicating who the contact was with in the Contact field.
- You can select Add Attachment to upload and store a file in connection with the treatment summary.
